HomeMy WebLinkAbout2003-P06499 - sewer/water connect PERMIT
CITY OF ORONO Permit Number:
2750 Ke,lley Parkway - PO Box 66 P06499 .
Cryst�l-Bay, Minnesota 55323 Pe�mit Type: Sewer and Water Pernut
(9��)�249-4600 Date Issued: �i2i2oo3
SITE ADDRESS: 3770 Shoreline Drive(City Park)
Wayzata,MN 55391
P I D: 17-117-23-34-0003
DESCRIPTION:
Proposed Use: Residential
Pernut Class: General
Pernut Type: Sewer and Water Pernut Pernut Sub-type(s): Sewer&Water Connections
DETAILS:
Approved per resolution#:
Separate pernuts required:
NOTICES/REMARKS:
FEE SUMMARY: Permit Fee: $ 105.00 Valuation: $ 0.00
State Surcharge Fee: $ 0.50
TOTAL FEE: $ 105.50
APPLICANT: Valley Rich Co. OWNER: City of Orono(Lift Station#30)
147 N.Jonathan Blvd-Suite A 1799 Lakeview Ter
Chaska,MN 55318 Long Lake,MN 55356
THE UNDERSIGNED HEREBY REQUESTS PERMISSION TO MAKE THE REAL IMPROVEMENTS SPECIFIED
AND AGREES TO DO ALL WORK IN STRICT COMPLIANCE WITH ALL CITY OF ORONO ORDINANCES AND STATE OF
MINNESOTA BUILDING CODE RE UIREMENTS.
. �
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APPLICANT ERMITEE SIGNATURE ISS D BY SIGNATURE
Copies: 1-File(SiQnitures Required), 1-Applicant, 1-Monthlv Reports, 1-Assessing, 1-Finance Page 1
Ju1-02-2003 10:44am From-CITY OF ORONO +9522494616 T-752 P.002/003 F-T22
CITY OF ORONO APPLICATION FOR UTILITY PERNIITS
Boz 66(2750 Kelley Parkway) SEWEIt/WATER
Crysta7 Bay,MN 55323
t
cEx�RaI.INFo�TTO�i �
1. You may apply for utiliry perinits by mail or in peison at the Ciry offices.
2. Mailed ia applications arc:subje�.K to the postage and handling fee shown below. Permit cards will be sent by return mail the same da�
the applicarion is received.
3. Permits are not valid until you receive a permit eard.
4. Work must not begin uniess the permit card is available on tha job site. •
5. Utility connection permi��raay be issued to licensed contractors only.
6. Contact the Public Wo�iss Department(952-249�600)for utiliry stub as-built locations. DO NOT EXCAVATE 1N ANY ST1tEET ANL
DO NOT TAP ANY MA1N without express approval of the Public Works Deparnnen� Issuance of a permit does not grant this approval
7, All work must be done in accordance with State Code requirements.
8, All work ruust be inspected before it u covered. Call(952)249-4600.
� 24 hoar notice required.
J4B SYTE ADDRESS: 3770 � o��iJe. � d�/'� /'e, �'�4�jon
Occupancy Type: Residential Comraercial
Owner's Narae:_��Q�i' nv Phone Number:
Mailing Address: � City: Zip=
Contractor's Name: � Phone Nnmber: g.��_9913'��-
Mailing Address:/47 IV ,� 4 City: Zip:
PERIVIIT TYPE
Municipal Sewer Connection($35.00 per stub) $ -��- ��
pipe size�inch�;s; material/e�L Schedule 40 air tested; cast iron
SAC Charge(2002 rate$1,200.00)must accompany all sewer pernut applications unless prepaitl. If not prepaid,a sewe
connection permit will not ba issued. �
Municipal W�ter Connection($35.00 per stub) �Z� $ ��-. d D
pipe size8 w Z'`inches; material�copper; other, L�1 l°
WATER MET'ERS must be�picked up and paid for at City Hall.
Water meters must be set a.nd sealed by Orono 'W�ter Department (952-249-4600) upon completion of inete
instatlation.
gEQUiRED mini.mum setbacks from drain field and septic tanks=75'
REQUIRED setback from sewer]ine=20' �
PFRNIIT FEE CALCULATYON
1. Subtotal of above permit requested $ �� • ��
2. State Surehar�e $ .50
The State Building Code Division Surcharge of$.SO per permit must be
included for each well,sewor and water connecdon permit requested.
3. Posta�e&Handlin�(Only mail-in applications) $ 1.50
4. TOTAL PERMIT FI'sE(add lines 1-3 above) $1�5_ 5�
The undersigaed hereby applies to the G�ry of Orono for issuance of a Utiliry Permit, agrees to do all work in stri�
accordance with the ordinan.ces of the City and the regulations of the State of Minnesota,and certifies that all statemen
made on this application are comp e,true and t.
.. .
Signature of Applic ► Date: a
MINNESOTA DEPARTMENT OF HEALTH - BONDING AND INSURANCE CERTIFICATE
This is to certify that Thomas H. Denison, Master Plumber License
No. •PM003809, representing Valley Rich Company has filed a $25,000 bond with
' the Secretary of State on October 29. 2002 and provided evidence of Public
, '~ Liability Insurance, including Products Liability Insurance of at least
. $50.000 per person and $100.000 per occurrence and Property Damage Insurance
of at least $10,000 for the year 2003 in accordance with the provisions of
Minnesota Statutes , Section 326.40.
BOND N0. RLI 495557 POLICY N0. CP22148614
Old Republic Surety Company Western National Mutual
Des Moines , Iowa Insurance Company
Mark Kiesow, Minnesota Agent
Eden Prairie, Minnesota
MR THOMAS H DENISON
VALLEY RICH COMPANY
147 JONATHAN BOULEVARD NORTH. NO. 4 ��� �. _���eo,,•�
CHASKA MN 55318 �^
Patricia A. Bloomgren. Director
Division of Environmental Health
� Jan K. Malcolm, Commissioner
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